Medical Surgical

Huntington’s Disease

Huntington;s disease is a chronic, hereditary disease of the nervous system that results in progressive involuntary choreiform (dance-like) movements and dementia.  Researchers believe that glutamine abnormally collects in certain brain cell nuclei, causing cell death.  Huntington’s disease affects men and women of all races. It is transmitted as an autosomal dominant genetic disorder. Each child of a parent with Huntington’s has a 50% risk of inheriting the illness. Onset usually occurs between 35 and 45 years of age.


  • The most prominent clinical features are abnormal involuntary movements (chorea), intellectual decline, ans emotional disturbance.
  • Constant writhing, twisting and uncontrollable movements of the entire body as the disease progresses.
  • Facial movements produce tics and grimaces; speech becomes slurred, hesitant, often explosive, and then eventually unintelligible.
  • Chewing and swallowing are difficult, and aspiration and choking are dangers.
  • Gait becomes disorganized, and ambulation is eventually impossible; patient is eventually confined to a wheelchair.
  • Bowel and bladder control is lost.
  • Progressive intellectual impairment occurs with eventual dementia.
  • Uncontrollable emotional changes occur but become less acute as the disease progresses. Patient may be nervous, irritable, impatient. During the early stages of illness: uncontrollable fits of anger; profound , often suicidal depression; apathy; or euphoria.
  • Hallucinations, delusions, and paranoid thinking may precede appearance of disjointed movements.
  • Patient dies in 10 to 15 years from heart failure, pneumonia, or infection or as a result of a fall or choking.


  • Diagnosis is made on the basis of clinical presentation, positive family history, and exclusion of other causes.
  • Imaging studies, such as computed tomography (CT), and magnetic resonance imaging (MRI), may show atrophy of striatum.
  • A genetic marker for Huntington;s disease has been located. It offers no hope pf cure or even specific determination of onset.


No treatment stops or reverse the process; palliative care is given.

  • Medications such as phenothiazines (haloperidol), butyrophenones, and thioxanthenes, which block dopamine receptors, and reserpine  and tetrabenazine. Anti-parkinsonism therapy (L-dopa) may improve chorea and temporarily decrease rigidity in some patients.
  • Motor signs are continually assessed and evaluated. Akathisia (motor restlessness) in the overmedicated patient is dangerous and should be reported.
  • Psychotherapy aimed at allaying anxiety and reducung stress may be beneficial; antidepressants are given for depression or suicidal ideation.
  • Patients needs and abilities are the focus of treatment.


  • Reinforcing understanding that Huntington;s disease takes emotions, physical, social and financial tolls on every member of the patients family.
  • Encourage genetic counseling, long-term psychological counseling, marriage counseling, and financial and legal support.
  • Teach patient and family about medications, including signs indicating need for change in dosage and medication.
  • Address strategies to manage symptoms (chorea, swallowing problems, ambulation problems, or altered bowel or bladder function).
  • Arrange for consultation with a speech therapist, if needed.
  • emphasize the need for regular follow-up.
  • Refer for home care nursing assistance, respite care, day care centers, and eventually skilled long-term care to assist patient and family to cope.
  • Provide information about the Huntington’s Disease Foundation of America, which gives information, referrals, education, and support for research.



Handbook for brunner & Suddarth’s textbook in Medical-Surgical Nursing 11th edition by Joyce Young Johnson

Lippincott Williams & Wilkins pp.450-452

Medical Surgical

Hodgkin’s Disease

Hodgkin’s disease is a rare cancer of unknown cause that is unicentric in origin and spreads along the lymphatic system. There is a familial pattern associated with Hodkin’s as well as an association with the Epstein-Barr virus (found 40% to 50% of patients). It is more common in men and tends to peak in the early 20s and after 50 years of age.  The Reed-Sternberg cell, a gigantic morphologically unique tumor cell that is thought to be  of immature lymphoid origin, is the pathologic hallmark and essential diagnostic criterion of Hodgkin’s disease. Most patients with Hodgkin’ disease have the types currently designated “nodular sclerosis” or “mixed cellularity”. The nodular sclerosis type tends to occur more often in young women ans at an earlier stage but has a worse prognosis than the  mixed cellularity subgroup. which occurs more commonly in men and causes more constitutional symptoms but has a better prognosis.


  • Painless enlargement of the lymph nodes on one side of the neck. Individual nodes are firm and painless; common sites are the cervical, supraclavicular, and mediastinal nodes.
  • Mediastinal lymh nodes may be visible on x-ray films and large enough to cause severe pressure symptoms (eg. dyspnea from pressure against the trachea; dysphagia from pressure against the esophagus).
  • Symptoms may result from the tumor compressing other organs, causing cough and pulmonary effusion (from pulmonary infiltrates); jaundice (from hepatic involvement or bile duct obstruction); abdominal pain (from splenomegaly or retroperitoneal adenopathy); or bone pain (due to skeletal involvement).
  • Pruritus is common and can be distressing; unclear etiology Herpes zoster  infection is common.
  • Some patients (20%) experience brief but severe pain after drinking alcohol, usually at the site of the tumor.
  • Mild anemia develops; the white blood cell count may be elevated or decreased; and energy (an absence of or decreased response to skin sensitivity tests such as candidal infection, mumps) may be noted.
  • Constitutional symptoms for prognostic purpose referred to as B symptoms, include fever (without chills), drenching sweats (particularly at night), and unintentional loss of more than 10% of body weight (found in 40% of patients and more common in advanced disease).


Diagnostic depends on identification of characteristic histologic features in an excised lymph node. After the diagnosis is confirmed, the total extent of tumor involvement is assessed and its distribution is defined.

  • Laboratory studies: complete blood count; platelet count, sedimentation rate, liver and renal function studies, RBC sedimentation rate and serum copper levels are used by some clinicians to assess disease activity.
  • Excisional  lymph node biopsy, bone marrow biopsy, characteristic presence of Reed-sternberg cell; staging of node.
  • Chest x-ray and computed tomography (CT) of chest, abdomen, and pelvis; positron emission tomography (PET) to detect residual disease.


Treatment id determined by the stage of the disease instead of the histologic type.

  • Chemotherapy followed by radiation therapy is used in early-stage disease.
  • Combination chemotherapy alone is now the standard treatment for more advanced disease.
  • When Hodgkin;s does recur, the use of high doses of chemotherapeutic medications, followed by autologous bone marrow or stem-cell transplantation, can be very effective.


  • Help patients to cope with undesirable effects of radiation therapy including esophagitis, anorexia, loss of taste, dry mouth, nausea and vomiting, diarrhea, skin reactions, and lethargy.
  • Serve bland, soft foods at mild temperature.
  • Teach patient about proper dental hygiene.
  • Administer antiemetics during peak times of nausea.
  • Teach patient that skin reactions are common; rubbing the area and applying heat, cold or lotion should be avoided.
  • Encourage patient to rest and sleep to maintain a  reasonable energy level; lethargy accompanies radiation.
  • Help patient to prepare for alopecia by encouraging him or her to purchase a wig before hair loss.
  • Encourage patient to report any sign of infection for immediate treatment.
  • Instruct patient to use contraception during chemotherapy to prevent cytotoxic effects on the fetus.
  • Encourage patient to keep all follow-up appointments.



Handbook for Brunner & Suddarth’s textbook of Medical-Surgical Nursing 11th edition by Joyce Young Johnson

Lippincott Williams & Wilkins pp.447-450




Medical Surgical

Hyperthyroidism (Grave’s disease)

Hyperthyroidism is the second most common endocrine disorder and Grave’s disease is the most common type. It results from an excessive output of thyroid hormones due to abnormal stimulation of the thyroid gland  by circulating immunoglobulins. Long-acting thyroid stimulator (LATS) is found significant in concentrations in the serum of many of these patients. The disorder affects women eight times more frequently than men and peaks between the second and fourth decades of life. It may appear after an emotional shock, stress, or infection, but the exact significance of these relationships is not understood. Other common causes include thyroiditis and excessive ingestion of thyroid hormone (eg. from treatment of hypothyroidism)


Hyperthyroidism presents a characteristic  group of signs and symptoms (thyrotoxicosis).

  • Nervousness (emotionally hyperexcitable), irritability, apprehensiveness; inability to sit quietly; palpitations, rapid  pulse on rest and exertion.
  • Poor tolerance of heat; excessive perspiration; skin that is flushed and likely to be warm, soft and moist
  • Dry skin and diffuse pruritus in the elderly
  • Fine tremor of the hands
  • Exophthalmos (bulging eyes) in some patients
  • Increased appetite and dietary intake, progressive loss of weight, abnormal muscle fatigability, weakness, amenorrhea, and changes in bowel function (constipation or diarrhea)
  • Pulse ranges between 90 and 160 beats/min with sinus tachycardia or dysrhythmias; systolic (but not diastolic) blood pressure elevation (increased pulse pressure).
  • Atrial fibrillation; cardiac decompensation in the form of congestive heart failure, especially in the elderly
  • Osteoporosis and fracture
  •  May include remissions and exacerbations, terminating with spontaneous recovery in a few months or years
  • May progress relentlessly; causing emaciation, intense nervousness, delirium, disorientation, and eventually myocardial hypertrophy and heart failure.


  • Thyroid glands is enlarged; it is soft and may pulsate; a thrill may be felt and a bruit heard over thyroid arteries
  • Laboratory tests show a decrease in serum TSH, an increase in serum thyroxine (T4) level and an increase in 123I or 125I uptake in excess of 50%.

Gerontologic Considerations

Elderly patients commonly presents with vague and nonspecific signs and symptoms. The major symptoms in the elderly patient may be depression and apathy, accompanied by significant weight loss and constipation in some. The patient may report cardiovascular symptoms and difficulty climbing stairs  or rising from a chair because of muscle weakness; congestive failure may be noted. Elderly patients may experience a single manifestation, such as atrial fibrillation, anorexia, or weight loss.  These general symptoms may mask underlying thyroid disease. Spontaneous remission of hyperthyroidism is rare in the elderly. Measurement of thyroid-stimulating hormone (TSH) uptake is indicated in elderly patients with unexplained physical or mental deterioration . Use of 123I or 131I is generally recommended for treatment of thyrotoxicosis rather than surgery unless an enlarged thyroid gland is pressing on the airway. Thyrotoxicosis must be controlled by antithyroid drugs before 131I is used because radiation may precipitate thyroid storm, which has a high mortality rate in the elderly.  Beta-blockers may be indicated. Use these agents with extreme caution ans monitor closely for granulocytopenia. Modify dosages of other medications because of the altered rate of metabolism in hyperthyroidism.


Treatment is directed toward reducing thyroid hyperactivity for symptomatic relief and removing the cause of complications. These forms of treatment are available:

  • Irradiation involving the administration of 131I or 123I for destructive effects on the thyroid gland.
  • Pharmacotherapy with antithyroid medications.
  • Surgery with the removal of the most of the thyroid gland.

Radioactive Iodine (131 I)

  • 131 I is given to destroy the overactive thyroid cells (most common in the elderly).
  • 131 I is contraindicated in pregnancy and nursing mothers because radioiodine crosses the placenta and is secreted in breast milk.


  • The objective of pharmacotherapy is to inhibit hormone synthesis or release and reduce the amount of thyroid tissue.
  • The most commonly used medicatioins are propylthiouracil (Propacil, PTU) and methimazole (Tapazole) until patient is euthyroid.
  • Maintenance dose is established, followed by gradual withdrawal of the medication over the next several months.
  • Antithyroid drugs are contraindicated in late pregnancy because of the risk for goiter and cretinism in the fetus.
  • Thyroid hormone may be administered to put the thyroid to rest.

Adjunctive Therapy

  • Potassium iodide, Lugol’s solution, and saturated solution of potassium iodide (SSKI) may be added.
  • Beta-adrenergic agents may be used to control the sympathetic nervous system effects that occur in hyperthyroidism; for example; propanolol is used for nervousness, tachycardia, tremor, anxiety, and heat intolerance.

Surgical Intervention

  • Surgical intervention (reserved for special circumstances)removes about five sixths of the thyroid tissue.
  • Before surgery, the patient is given propylthiouracil until signs of hyperthyroidism have disappeared.
  • Iodine is prescribed to reduce the thyroid size and vascularity and blood loss. Patient is monitored carefully for evidence of iodine toxicity (swelling buccal mucosa, excessive salivation, skin eruptions).
  • Risk for relapse and complications necessitates long-term follow-up of patient undergoing treatment of hyperthyroidism.
  • Surgery to treat hyperthyroidism is performed after thyroid function has returned to normal (4 to 6 weeks).



Handbook for Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th edition by Joyce Young Johnson

Lippincott Williams and Wilkins pp.461-464

Medical Surgical

Parkinson’s Disease

Parkinson’s disease is a slowly progressive degenerative  neurologic disorder affecting the brain center that are responsible for control and regulation of movement. The degenerative or idiopathic form of Parkinson’s disease is the most common; there is also a secondary form with a known or suspected cause. The cause of the disease is mostly unknown. The disease usually first appears in the fifth decade of life and is the fourth most common neurodegenerative disease.


Stores of the neuotransmitter dopamine are lost in the substantia nigra ans the corpus striatum because of a degenerative process. The loss pf dopamine stores in this area of the brain results in excitatory neurotransmitter than inhibitory neurotransmitters, leading to an imbalance that affects voluntary movement . Other neurotransmitter pathways (responsible for cell metabolism, growth, nutrition, and so forth) may be involved as well. Cellular degeneration causes impairment of the extrapyramidal tracts that control semiautomatic functions and coordinated movements. Regional cerebral blood flow  is reduced, and there is a high prevalence of dementia. Biochemical and pathologic data suggest  that patients with Parkinson’s disease and dementia may have coexistent Alzheimer’s disease.


The three cardinal signs of Parkinson’s disease are tremor, rigidity, and bradykinesia (abnormally slow movements).

  • Impatient movement: bradykinesia includes difficulty in initiating, maintaining, and performing motor activities, muscle stiffness or rigidity
  • Resting tremors: a slow unilateral turning of the forearm and hand and pill-rolling motion of the thumb against the fingers; tremors at rest and increasing with concentration and anxiety
  • Muscle weakness
  • Hypokinesia (abnormally diminished movement), gait disturbances, flexed posture, and postural instability (loss of postural reflexes, and the freezing phenomenon)


Patients tend to develop micrographia (shrinking, slow hand-writing) as dexterity declines. Additional characteristics include:

  • Dysphonia (soft, slurred, low-pitched, and less audible speech)
  • Masklike facial expression
  • Loss of postural reflexes: patients stand with head bent forward and walks with propulsive gait ( shuffling gait); difficulty pivoting and loss of balance, resulting in risk for falls.
  • Depression and psychiatric manifestaitons (personality changes, psychosis, dementia, and confusion)
  • Sleep disorders, uncontrolled sweating, orthostatic hypotension, gastric and urinary retention, and constipation


  • Patient’s history and presence of two of the three cardinal manifestations: tremor, muscle rigidity, and bradykinesia
  • Positron emission tomography (PET) scanning
  • Neurologic examination and response to pharmacologic management


Goal of treatment is to control symptoms and maintain functional independence; no approach prevents disease progression.

Pharmacologic Therapy

  • Levodopa therapy ( converts to dopamine): most effective agent to relieve symptoms; usually given in combination with carbidopa (Sinemet), which prevents levodopa breakdown.
  • Budipine is a non-dopaminergic, antiparkinson medication that significantly reduce akinesia, rigidity, and tremor.
  • Antihistamine drugs to allay tremors.
  • Dopamine agonists (eg. pergolide [Permax], bromocriptine mesylate [Parlodel], ropinirole, and pramipexole are used to postpone the initiation of carbidopa and levodopa therapy.
  • Anticholinergic therapy to control the tremor and rigidity.
  • Amantadine hydrochloride  (Symmetrel), an antiviral agent, to reduce rigidity, tremor and bradykinesia.
  • Monoamine oxidase inhibitors (MAOI’s) to inhibit dopamine breakdown
  • Anntidepressant drugs
  • Trials of catechol-O-methyltransferase (COMT) inhibitors.

Surgical Management

  • Surgery to destory a part of the thalamus (stereotactic thalamotomy and pallidotomy) to interrupt nerve pathways and alleviate tremor or rigidity.
  • Transplantation of neural cells from fetal tissue of human or animal source to reestablish normal dopamine release.
  • Deep brain stimulation with pacemaker-like brain implants shows promise but is waiting for FDA approval.




Handbook for Brunner &Suddarth’s Textbook of Medical-Surgical Nursing 11th edition by Joyce Young Johnson

Lippincott Williams & Wilkins pp. 594-596

Medical Surgical

Cancer of the Cervix


Cancer of the cervix is predominantly (90%) squamous cell cancer and can include adenocarcinomas. It is less common than it once was because of early detection by the Pap test, but it remains the third most common reproductive cancer in women. it occurs most commonly between the ages of 35 and 45 years but can occur in women as young as 18 years. Risk factors vary from multiple sex partners to smoking to chronic cervical infection (exposure to HP virus).



  • Cervical cancer is most often asymptomatic. When discharge, irregular bleeding, or bleeding after sexual intercourse occurs, the disease may be advanced.
  • Vaginal discharge gradually increases in amount, becomes watery, and finally is dark ans foul-smelling because of necrosis of the tumor mass.
  • Bleeding occurs at irregular intervals between periods or after menopause, may be slight (enough to spot the undergarment), and is usually noted after mild trauma (intercourse, douching, or defecation). As disease continues, bleeding may persist and increase.
  • Nerve involvement, producing excruciating pain the back and legs, occurs as cancer advances and tissues outside the cervix are invaded, including the fundus and lymph glands anterior to the sacrum.
  • Extreme emaciation and anemia, often with fever due to secondary infection and abscesses in the ulcerating mass, and fistula formation may occur in the final stage.


  • Pap smear and biopsy results show severe dysplasia, HGSIL, or carcinoma in situ.
  • Abnormal Pap test may be followed by biopsy, dilation and curettage (D & C), computed tomography (CT), magnetic resonance imaging (MRI), intravenous utrography (IVU), cystogram and barium radiopgraphs.


Disease may be staged based on the International Classification staging system or TNM classification to determine treatment as well as progress of the cancer.

  • Conservative treatments include cryotherapy (freezing with nitrous oxide), laser therapy, loop electrosurgical excision procedure (LEEP), or conization (removing a cone shaped portion of the cervix).
  • Simle hysterectomy if invasion is less than 3 mm. Radical trachelectomy is an alternative to hysterectomy.
  • For invasive cancer , radical hysterectomy, radiation (external-beam or brachetherapy), or chemotherapy (cisplatin, carboplatin, and paclitaxel [Taxol] or a combination of these approaches may be used.
  • For recurrent cancer, pelvic exenteration is considered.


Chapter 1:

Health Promotion and Disease Prevention


1.The nurse explains that the belief advancing the idea that disease is a result of an organically caused disorder is the

a.    biomedical model.

b.    biopsychosocial theory.

c.    Dunn’s high-level wellness model.

d.    Travis’ health model.

Answer:    A

The biomedical model describes disease as an organically caused disorder with consistent clinical manifestations. The biopsychosocial theory claims that disease is caused by the interaction of environmental, physical, and social factors. Dunn wrote about high-level wellness. The model by Travis emphasizes that wellness requires work and attention.

2. The nurse explains that the client’s ability to cope with stress dynamically will play a significant role in the client attaining maximum potential. This approach is most consistent with the model of

a. King

b. Leninger

c. Levine

d. Neuman

Answer: A

King’s theory suggets that continous adjustment to stressors, both internal and external, with the use of one’s resources allows the person to attain maximum potential.

3.When the nurse encourages a Native American to seek health counsel from the tribe’s shaman, the nurse is following the tenets of:

a. King

b. Leninger

c. Pender

d. Rogers

Answer: B

Leninger postulates that health refers  to culturally known and utilized practices that maintain personal and group well-being.

4. The nurse using the World Health Organization (WHO) description of health bases care on the premise that health is

a.    a gift from a higher being.

b.    any disease-free condition.

c.    complete mental, physical, and social well-being.

d.    high-level functioning despite illness.

Answer: C

The most widely accepted definition is the classic 1947 WHO description of health as “a state of complete physical, mental and social well being and not merely the absence of disease or infirmity.”

5. The nurse planning a health promotion program with clients in the community will focus least on

a.    assisting the clients to make informed decisions.

b.    organizing methods to achieve optimal mental health.

c.    providing information and skills to maintain lifestyle changes.

d.    reducing genetic risk factors for illness.

Answer: D

Health promotion programs are designed to improve the health and well-being of individuals and communities by providing people with information, skills, services, and support they need to undertake and maintain positive lifestyle changes. Genetic risks for illness cannot be controlled to promote health.

6.    A holistic belief system by the nurse would be most evident if the nurse

a.    accepts death as an outcome of life.

b.    encourages behavior modification programs.

c.    incorporates client perceptions of health when planning care.

d.    supports goal-directed learning to improve health.

Answer: C

The theories of Orem, Rogers, and Roy focus on the holistic view, which takes the client and the client’s beliefs, values, and culture as necessary considerations to comprehensive care.

7.    The nurse understands that the document he/she can use to plan community teaching projects addressing the federal population-based health objectives is

a.    Healthy People 2010.

b.    Nursing’s Agenda for Healthcare.

c.    the federal Medicare/Medicaid Acts.

d.    the Goldmark Report.

Answer:    A Healthy People2010 contains federal population-based health objectives and identifies leading indicators of health that apply to adults.

8.    The nurse recognizes the activity that reflects primary prevention is

a.    a self-initiated walking regimen.

b.    collaboration with a physical therapist.

c.    physician-prescribed exercise after a heart attack.

d.    tuberculosis screening.

Answer:    A

Primary prevention is an activity that is done before any illness, but as a preventive effort to avoid illness. Collaboration with a physical therapist and physician-prescribed exercise after a heart attack are both tertiary prevention: measures intended to reduce the effects of an established health problem. Screening activities, designed for early detection, are secondary prevention.

9.    The nurse is planning a community STD (sexually transmitted disease) screening fair. This activity would be considered

a.    epidemiologic prevention.

b.    primary prevention.

c.    secondary prevention.

d.    tertiary prevention.

Answer: C

Secondary prevention activities are those that include screening and early diagnosis.

10.The nurse is developing a teaching plan for a 60-year-old man who experienced a cerebrovascular accident (CVA). The nurse works with the client to prevent aspiration when eating. This is an example of

a.    epidemiologic prevention.

b.    primary prevention.

c.    secondary prevention.

d.    tertiary prevention.

Answer:    D

Tertiary prevention is directed toward rehabilitation after a disorder already exists. The interventions are directed toward minimizing disability and improving quality of life.

11. The nurse is counseling an overweight young man on entry into a weight reduction and exercise program. The nurse is aware that the client is most likely to begin and maintain the program if he

a.    can envision himself as thinner.

b.    feels competent about making the change.

c.    has read about the program.

d.    is aware of being overweight.

Answer:    B

Clients are more likely to be motivated to change if they feel competent to do it and have social support.

12.    The nurse is caring for a 35-year-old client at risk for cardiovascular disease. The client states he is aware that he must “maintain a low-fat diet.” Using the Transtheoretical Model and Stage of Change, the nurse assesses that this client is at the stage of

a.    action.

b.    contemplation.

c.    maintenance.

d.    pre-contemplation.

Answer:    B

The contemplation phase describes the client as seriously thinking about a change. In the action phase, the client is implementing the behavior change; in the maintenance phase the client continues to move forward with the change, and in the pre-contemplation phase the client has not yet thought about changing his behavior.

13.The nurse can “empower” a client in adjusting to the changes associated with the chronic effects of non–insulin-dependent diabetes mellitus by

a.    explaining that concerns about vision changes are premature at this point.

b.    explaining the pathophysiology of the disease.

c.    informing the client about the different types of insulin.

d.    teaching the client how to minimize complications.

Answer:    D

Empowering gives the client information, skills, and contact with services available to deal with the client’s disease.

14.Suggestions that a home health nurse could make to an elderly client with cataracts to reduce the risk of falls in his home would include

a.    arranging scatter rugs to prevent slipping on the hardwood floor.

b.    using lower-illumination bulbs to prevent eyestrain.

c.    using night lights in every room.

d.    wearing soft-soled house shoes indoors.

Answer:    C

The visual impairment requires increased illumination and an uncluttered environment. Soft-soled shoes enhance the fall potential as do scatter (or “throw”) rugs.

15.During a nursing history before a physical exam, a nurse identifies a client as being in a violent relationship. The most important intervention by the nurse at this time is to

a.    ask the physician to order a series of x-rays to look for old broken bones.

b.    call the police if the abusive partner is in the waiting room.

c.    help the woman develop an individual plan to diminish future abuse.

d.    refer her to the local battered women’s shelter.

Answer:    C

The priority intervention at this time is to help the woman develop an individualized plan to avoid future abuse. The emphasis must be on safety because the woman has a high risk for significant injury or death. Part of the safety plan can include information on shelters available in the local area, but referral to a shelter does not diminish the nurse’s responsibility to help the woman remain safe.

16.A client is having a physical examination and asks the nurse if his father, age 76, should have the same prostate cancer screening that he is having. The nurse bases her answer on knowledge that

a.    a simple blood test is all that is required for prostate cancer screening.

b.    all men, regardless of age, need routine prostate cancer screening.

c.    men over age 70 generally do not need routine prostate screening.

d.    only members of certain high-risk ethnic groups need regular screening.

Answer:    C

Generally, men over the age of 70 or who have a significant illness that will probably result in a life span of less than 10 more years are not routinely screened for prostate cancer. Screening should start at age 50 or earlier for high-risk ethnic groups and consists of a prostate-specific antigen test and digital rectal examination.

17.A nurse is teaching women breast self-examination (BSE). When designing a teaching program, the nurse is aware that the biggest barrier to women doing BSE is

a.    better screening tools like mammograms.

b.    discomfort and pain when doing the exam.

c.    lack of confidence when performing the exam.

d.    realization that breast cancer is not a leading cause of cancer death in women.

Answer:    C

A major barrier to BSE is a lack of confidence. Breast cancer is the second leading cause of cancer death in women. While mammogram is a more sensitive tool, it is costly and is only recommended every 1 to 2 years, while BSE is recommended monthly. A BSE is not uncomfortable.

18.     A nurse is presenting information at a community forum related to pneumonia. The nurse informs the audience that people who should receive the pneumococcal vaccine include those who (select all that apply).

a.    are over age 65 and had a vaccination more than 5 years ago.

b.    are under age 65 and are alcoholics.

c.    are under age 65 with chronic illnesses.

d.    are over age 65 and have never had pneumococcal pneumonia before. e.    are over the age of 65.

Answer:    A, B, C, D

All adults over age 65 should have a pneumococcal pneumonia vaccination and they should be re-vaccinated if it has been more than 5 years since their previous vaccination. Individuals younger than 65 are considered high risk and should have the vaccination if they are alcoholics, have chronic illnesses, are members of certain high-risk ethnic and social groups, or have sickle cell anemia or have had their spleen removed.

19. Place the steps for breast self-examination (BSE) in the order a nurse should teach a client to do them (select all that apply).

a.    Feel both breasts while lying down.

b.    Feel both breasts while sitting or standing.

c.    Gently squeeze each nipple to look for discharge.

d.    Look at your breasts in the mirror with your arms on your hips.

e.    Look at your breasts in the mirror with your arms raised.

Answer:    A, B, C, D, E

This is the proper sequence for BSE. BSE should be done at the end of the menses in women who still menstruate, and on the same day of each month in post-menopausal women.

20. Strategies a nurse should use when teaching a client include (select all that apply)

a.    using plain, lay language.

.    providing comprehensive information at each session.

c.    having the client “teach back” what has been taught.

d.    using written material written at a low literacy level.

Answer:    A, C, D

Strategies for teaching include (1) using plain, lay language; (2) limiting the amount of information given at any one time; (3) using teach-back techniques; (4) using diagrams; and (5) using written material that is at a low literacy level. Estimates are that one third to one half of people in the United States experience low health literacy.

21. A nurse teaching a client using self-management support strategies would include measures to help the client increase his/her (select all that apply)

a.    compliance with recommendations.

b.    decision-making abilities.

c.    health literacy.

d.    problem-solving skills.

e.    resource utilization

Answer:    B, C, D, E

The five self-management skills that form the core of Loring’s self-management support program are problem-solving, decision-making, resource utilization, empowered client role, and health literacy.

Chapter 2: Health Assessment

1.A nurse is collecting a health history from a client and feels the client is not reliable. One recommended way to verify some of the client data is to

a.    ask the client the same questions but in a different manner.

b.    confront the client with your suspicions.

c.    find and question a secondary source.

d.    have another nurse try to get data from the client

ANS:    C

Clients may be poor historians and unable to provide accurate data. If there is a secondary source such as a significant other or family member available, ask them some of the health history questions. A client who is confused will not be able to answer accurately even if you ask questions in different ways. Confrontation can lead to alienation. Having another nurse question an unreliable client is unlikely to garner valid data.

2.The nurse is collecting a health history on a middle-aged African American male. The nurse asks about past blood pressure screening because the incidence of hypertension is higher in this ethnic group than in others. This is an example of

a.a generalization based on the nurse’s limited experience with African Americans.

b.bias, and the nurse should not question the client about blood pressure screening.

c.stereotyping the client based on the client’s ethnic/racial group.

d.using valid research data to focus questions on the client’s specific risks.

ANS:    D

Reliable research finding concerning group characteristics or similarities may be applied to a specific client who belongs to that group. Generalizations, stereotypes, and biases have no place in nursing care.

3.A client had surgery yesterday and is complaining of pain. The best action by the nurse is to

a.ask the patient which pain medication she/he took last. a complete assessment of the pain.

c.prepare to administer the ordered pain medication.

d.record the client’s complaints thoroughly and get the pain medication.

ANS:    B

This is an example of symptom analysis. Nurses should use a recognized approach to fully assess each client complaint, such as the OLDCART or PQRST method. It is best to understand the source of a complaint before treating it. In this case, the postoperative client could be having a nonrelated problem such as angina. Without a further assessment, the nurse would administer the postoperative pain medication, which might mask the new symptoms or delay diagnosis and treatment.

4.A client is being admitted to the hospital and the nurse has the client’s electronic record, including past medical history. What should the nurse do with this information?

a.Copy the information from the electronic database to the admission database.

b.Not use it because it is preferred to ask clients about past history at each encounter.

c.Save time and skip this part of the history-taking because the record is electronic.

d.Verify with the client that the list is current, complete, and correct.

ANS:    D

A previously recorded past health history is useful to have, but the nurse must verify its accuracy with the client. Diagnoses may change because of second opinions, because they have been cured, or because they have been surgically corrected.

5.To assess precipitating factors, the nurse interviewer would ask

a.“Do you remember the first time you had this problem?”

b.“How many times has the problem been related to activity?”

c.“What measures relieve this problem for you?”

d.“What were you doing when you first noticed the problem?”

ANS:    D

To ask what the client was doing and where he was at the time the manifestation was noticed is an abbreviated way to obtain information as to cause or environmental precipitators. The other options are related to timing, aggravating factors, and remedy.

6.Because the psychosocial assessment includes many more personal aspects of the client’s history, the most significant variable that may affect the quality and usefulness of the collected data is the

a.nurse’s ability to establish a therapeutic relationship.

b.nurse’s difficulty in differentiating normal from abnormal.

c.reluctance of most clients to share information with health care providers.

d.value the client places on the health interview.

ANS:    A

The client must feel comfortable to share some of the information assessed in the psychosocial portion; therefore the nurse’s ability to establish a therapeutic relationship is the major element in securing accurate data.

7.In the preparation of a nursing care plan relative to the client’s mental status, the least helpful data would be those resulting from

a.client’s overall response to the interview.

b.formal psychological tests.

c.notation of appropriateness of affect.

d.observation of nonverbal behavior.

ANS:    B

Mental status assessment consists of evaluation of verbal and nonverbal responses to the individualized questions, as well as evaluation of mood and affect. Psychological tests cannot measure these factors.

8. A client is brought to the emergency department in serious condition and needs an operation within the next hour. Which of the following principles does the nurse use to guide the health history? (Select all that apply.)

a.Assess the client’s current health status.

b.Collect data pertinent to the immediate problem.

c.Strive to collect only pertinent data while being thorough.

d.Update the database when the client’s condition allows.

e.Use a systematic approach to gather the client’s entire health history.

ANS:    A, B, C, D

Many factors influence the depth of health history the nurse should obtain. In this case, the client is in an emergent situation that does not warrant gathering information on the client’s entire history. However, for client safety, the nurse must assess the client’s current health status, collect data relevant to the current situation, and strive to be as thorough as possible within these limitations. When the client is more stable, more data can be collected.

9. The nurse collecting data on a client’s social history asks questions regarding the client’s (select all that apply)

a.exposure to communicable diseases.

b.home life.

c.immunization history. roles.

ANS:    A, B, D, E

Immunization history, while an important component of health history, is not included in social history.

10. Which principles of assessment does the nurse use when working with hospitalized clients? (Select all that apply.)

a.Assess each client at the beginning of each shift.

b.Base the frequency of assessment on client condition.

c.Begin with the most seriously ill client.

d.Record findings as they are assessed, not later.

e.Wait for physician orders to determine the frequency of assessments.

ANS:    A, B, C, D

These answers are all good principles on which to base nursing assessments. Assessing a client is an independent nursing function. While the physician may write for assessments to be done at a specified minimum time frame, nurses use their own professional judgment to obtain client assessments as appropriate.

Chapter 3: Critical Thinking

1. The process by which a nurse uses purposeful thinking, informed reasoning, reflections, and thinking about thinking in clinical situations is called a.    clinical judgment.

b.    critical thinking.

c.    decision making.

d.    problem solving.

ANS:    B

Critical thinking is a process of thinking that ensures conclusions are self-correctable, reasonable, informed, and precise. This is done through informed reasoning, purposeful thinking, reflecting on situations, and thinking about one’s thinking. Clinical judgment uses experience to guide assessments and decision making. Decision making involves using the scientific process to identify a specific problem, assess and weigh all options, test possibilities, and consider the consequences of the choice of action. Problem solving is more focused with the selection of only pertinent information about the problem and evaluating the solution over time. All are part of critical thinking but none are as broad.

2.It is crucial for the nurse to be able to make sound decisions using critical thinking because is the most efficient use of the nurse’s time and resources. uses previously learned knowledge in predictable situations.

c.most clients have problems for which there are no textbook answers.

d.nurses can recognize problems rapidly and provide speedy responses to situations.

ANS:    C

Most client care situations are unique—not predictable—and nurses must adapt previously learned knowledge to new circumstances, drawing from multiple sources of information. It may well be more efficient and rapid, but that is not the primary reason critical thinking is valuable.

3.A nurse with 6 year’s labor and delivery experience is floated to the intensive care unit. In this situation, the nurse would most likely function at the level of

a.    advanced beginner.

b.    competent.

c.    novice.

d.    proficient.

ANS:    C

According to Benner’s Five Levels of Competency in Nurses, a novice is one who has no experience in situations in which they are expected to perform. This nurse would need specific rules to guide action. An advanced beginner has seen enough real situations to note recurring and meaningful components of the situation. A competent nurse has been on the job or in similar situations for 2-3 years. A proficient nurse has a great deal of situational perception as the result of 3-5 years of experience.

4.A nurse is working in the intensive care unit. When assessing the clients, the nurse notes one of them, who was scheduled to transfer to a step-down unit as soon as a bed becomes available, has a respiratory rate change from 18 to 20 breaths/min and an oxygen saturation (O2 sat) of 92%, when earlier it was 93%. The client denies complaints. The nurse calls the physician and requests a chest x-ray and arterial blood gases (ABGs). This nurse is working at which Benner Level of Competency in Nurses?

a.    Advanced beginner

b.    Competent

c.    Expert

d.    Proficient

ANS:    C

The expert nurse is able to grasp the important components of a situation intuitively, noticing subtle changes, and zeroing in on the problem immediately. This nurse is also flexible. The advanced beginner is not flexible, is slow to act, and still needs rules to guide practice. The competent nurse is beginning to be able to master many situations in nursing but is still somewhat slow. The proficient nurse is perceptive and sees subtle changes rapidly, but would not be able to zero in on the problem as rapidly as the expert nurse.

5.A nurse is confused about the best way to confirm placement of a small flexible feeding tube before giving a bolus feeding. Colleagues on the unit suggest several different methods. The best process by which to determine a policy outlining the appropriate course of action is

a.    critical reasoning.

b.    evidence-based practice.

c.    problem solving.

d.    professional judgment.

ANS:    B

Evidence-based practice (EBP) is a process by which nurses make clinical decisions using the best available research evidence, clinical expertise, and client preferences to guide actions. There are several steps necessary to solve problems using this method. None of the other options provides as broad a foundation for a practice change as EBP, which utilizes research in the literature to inform practice changes, which are then evaluated for institutional fit and feasibility.

6.A nurse who is alert to changes, confident, open-minded, proactive, and questioning is displaying which characteristics?

a.Alfaro’s Attitudes and Characteristics of a Critical Thinker

b.Benner’s Five Levels of Competency in Nurses

c.Hawk’s Model of Critical Thinking in Registered Nurses

d.Universal Intellectual Standards

ANS:    A

There are 29 attitudes and characteristics of a critical thinker listed in Box 3-1, 5 of which are listed here. Benner’s model has 5 levels of nursing competency: novice, advanced beginner, competent, proficient, and expert. The Universal Intellectual Standards encourage thoughtful examination of clinical problems. There is no Hawk’s Model of Critical Thinking in Registered Nurses.

7. A nurse brings a client a medication that is scheduled once daily with food. The medication administration record lists it as being due at 9:00 AM. The client refuses the medication, asking to take it later. The nurse replies “That’s OK. I can give it to you with your lunch if you like.” Which statement about the nurse is correct? The nurse

a.    is being flexible and logical.

b.    just made a medication error.

c.    needs to call the doctor.

d.    should tell the patient to take the medication now

. ANS:    A

Flexible and logical are two attitudes and characteristics of a critical thinker. Hospital pharmacies often schedule once-a-day medications at 9:00 AM. The important aspect of this medication is that it is indeed given once a day and with food. The time of day does not matter as long as it is consistent. The nurse could call the pharmacy and ask them to change the time on the medication administration record. The other three options all demonstrate inflexibility and rule-bound behavior.

8. At the beginning of the shift a student nurse is meeting with the registered nurse (RN) assigned to the student’s client. The student nurse should provide the RN with which information? (Select all that apply.)

a.Assessments the student will make

b.Documentation the student will complete

c.Medications the student will administer

d.Treatments the student can perform

e.What time the student is going to lunch

ANS:    A, B, C, D

These are all important components of the student’s report to the RN. The time the student will take lunch is not crucial to discuss at this time and may well change depending on client status and needs at lunchtime.

Chapter 4: Complementary and Alternative Therapies

1. According to the National Center for Complementary and Alternative Medicine, complementary medicine is

a.prescribed and overseen by a medical physician.

b.treatment of a physical illness by a spiritual intervention.

c.used in place of conventional medicine.

d.used together with conventional medicine.


Complementary medicine is used together with conventional medicine, such as using aromatherapy to help reduce discomfort after surgery.

2.Of the many complementary and alternative medicine (CAM) modalities available in the United States, the most rapidly growing area is



c.dietary supplementation.



Dietary supplementation is currently the most rapidly growing CAM modality in the United States.

3.A nurse taking the history of a client with rheumatoid arthritis might be alerted to the client’s use of CAM when the client says

a.“A bunch of nuts believe that putting nice smells in the air cures arthritis.”

b.“Doctors don’t know everything, you know.”

c.“I’ve heard something about alternative medicine. What is that?”

d.“What do you think about biofeedback?”


The most “nondisclosing” client remark is asking the nurse about a specific alternative modality and “testing the waters” relative to the nurse’s response to that specific modality.

4.When the client asks the nurse about the use of therapeutic herbs, the nurse’s most instructional response would be

a.“Herbs are not regulated and may pose health risks if used with prescribed drugs.”

b.“Herbs have many qualities; some effects are good, and some are not.”

c.“I have heard many people have used some herbal remedies and had good results.”

d.“If you are getting relief from some herbal remedy, there is probably no harm in it.”


Herbs are not regulated, and some herbs can interfere with the therapeutic effects of some drugs and can react unfavorably with anesthesia and surgical intervention.

5.The nurse reminds a client that the Dietary Supplement and Health Act of 1994 prevented manufacturers of dietary supplements from

a.making specific therapeutic claims for the product on their labels.

b.manufacturing products that are not tested or proven.

c.offering products for sale except through pharmacies.

d.publishing outrageous claims for the product on promotional materials.


This act forbids claims for specific results from being placed on the label, although outrageous claims may be made on websites and in promotional materials.

6.When the client asks the nurse what “placebo effect” means, the nurse includes in the response that the placebo effect describes a

a.deterioration of the product to the point that it renders the product incapable of offering any therapeutic benefit.

b.phenomenon of a person taking the placebo and claiming positive effects because of psychological factors unrelated to the product.

c.practice of manufacturers to make hugely inflated claims to induce the potential user to believe in the worth of the product.

d.product that, although producing therapeutic effects for many users, has no effect on others.


Placebo effect is the phenomenon of persons given the placebo in testing and then claiming positive benefits from the product based on psychological factors unrelated to the product.

7.A nurse understands that many conventional drugs are derived from plants, such as

a.meperidine (Demerol).





Quinine is derived from cinchona. The other options are manufactured from chemical compounds or derived from hormones.

8.The nurse cautions that, when consumed in large quantities, antioxidants can become pro-oxidants, which

a.absorb large quantities of free radicals.

b.can produce free radicals.

c.create a free radical “shield.”

d.enhance the immune system.


Pro-oxidants, which can develop from the concentrated use of large amounts of antioxidants, can produce millions of free radicals. They do not absorb free radicals, create a free radical shield, or enhance the immune system.

9.A young Hispanic woman tells the nurse that she is going to have a healing ritual to center her spirit after the recent death of her husband. The nurse recognizes the alternative medicine system of




d.Tai Chi.


Curanderismo is the practice prevalent in the Hispanic culture of spiritual rites and rituals to promote healing. Ayurveda is practiced primarily in the Indian subcontinent and includes diet, herbal remedies, and massage. Reiki is the Japanese health belief that when spiritual energy is channeled through a Reiki practitioner, the client’s spirit is healed, subsequently healing the physical body. Tai Chi is an ancient form of martial arts that uses slow, controlled movements, meditation, and breathing to improve overall health and well-being.

10.An elderly Chinese woman tells the nurse that she must improve the flow of her Qi. The nurse asks the client how long she has been using



c.Tai Chi.


Acupuncture is an ancient Oriental practice of placing needles in certain points of the body to improve the energy flow of Qi throughout the body to improve health. Ayurveda is practiced primarily in the Indian subcontinent and includes diet, herbal remedies, and massage. Tai Chi is an ancient form of martial arts that uses slow, controlled movements, meditation, and breathing to improve overall health and well-being. Yoga is an exercise that teaches specific postures and breathing exercises. It has been shown to reduce stress levels and improve relaxation.

Chapter 5: Ambulatory Health Care

1. Ambulatory care nursing is an emerging field of nursing practice in which the nurse

a. deals with clients who are ambulatory and able to walk into the clinic.
b. is part of an interdisciplinary team offering primary, secondary, and tertiary care.
c. offers an integrated system of care to persons within walking distance of the clinic.
d. works only with clients who are not acutely ill.

Answer: B
The ambulatory nurse takes care of clients who are healthy, acutely ill, and chronically ill. Ambulatory nurses function as a member of an interdisciplinary team.

2. Ambulatory care centers include available 24 hours a day, 7 days a week. for short-term medical-surgical procedures. for those unable to provide self-care after a procedure.
d.sleeping accommodations for a family member.

Answer: B
Technological advances allow treatment in a short-term facility that previously required a hospital stay. Ambulatory care centers meet the needs of these clients and avoid a costly inpatient stay. They may or may not be open 24 hours, 7 days a week. A person who needed help with self-care would probably need in-home or hospital care. And since care duration is less than 24 hours, sleeping accommodations are not provided as part of ambulatory care centers.

3. The nurse manager of an ambulatory care center assesses the center for environmental hazards to comply with guidelines of both the local state health department and the

a.Ambulatory Care Nursing Administration and Practice.
b.American Nurse’s Credentialing Center.
c.Nurse Practice Act.
d.Occupational Safety and Health Administration.

Answer: D
The Occupational Safety and Health Administration (OSHA) and the state health department oversee environmental factors. The other three options address professional practice and credentials.

4. The facility that could best represent an ambulatory care center is a

a.home health care agency. with less than 50 beds.
c.rehabilitation center.
d.student health center.

Answer: D
The student health center is an ambulatory care center. The other options provide care to clients in their home, to inpatients, or as a prescribed follow-up service.

5. In comparing the ambulatory care setting to an inpatient hospital setting, the nurse- instructor is correct in stating that the ambulatory care setting

a.has had so many cost increases that a visit is just as costly as the hospital. already in decline and offers limited employment opportunities.
c.may create a feeling of greater stress to the client than a hospital setting.
d.provides an environment where the client is less at risk for nosocomial infection.

Answer: D
The client using an ambulatory care center is exposed less to nosocomial infection and other hazards of hospitalization. Care is much more cost-efficient in ambulatory care centers. Employment opportunities are increasing in ambulatory care. Ambulatory care centers often are less stressful than hospitals for clients.

6.A nurse working in an ambulatory care setting would provide secondary prevention activities such as

a.carrying out hypertension screening. instructions after minor surgery.
c.providing cardiac rehabilitation.
d.teaching young adults the benefits of good nutrition.

Answer: A
Screening activities are secondary prevention. Teaching nutrition and giving instructions to prevent complications after minor surgery are both primary prevention. Cardiac rehabilitation is an example of tertiary prevention.

7.The nurse instructor describes an integrated delivery system and cites the example of

a.a hospital’s alignment with several physician groups to increase hospital referral. outpatient clinic in the hospital.
c.enrollees of the system being “locked” into the system of care for services.
d.providers concerned about generating revenue.

Answer: A
Hospitals have aligned themselves with groups of physicians to increase hospital referral and provide greater coordination of care.

8.A health care service that provides a defined population with a stated range of services through prepayment of an annual or monthly capitation fee is a(n) maintenance organization (HMO).
b.nurse-managed ambulatory center.
c.outpatient service of a community hospital.
d.preferred provider organization (PPO).

Answer: A
An HMO provides services to members for an annual or monthly capitation fee. Physicians who contract with a preferred provider organization get paid at a reduced rate for each service they provide.

9.The facility least suited to the provision of primary health care is a(n)

a.ambulatory care center.
b.emergency department.
c.HMO. outpatient clinic.

Answer: B
Emergency departments (EDs) are organized according to the clinical model and are essentially dedicated to meet acute care needs. Providing primary care is a basic function of the ambulatory care center. An HMO is an organization with which physicians contract to receive payment for caring for enrollees. Primary health care could be provided at a hospital outpatient clinic.

10.The nurse-manager explains to a new nurse at the ambulatory clinic that the service for which the telephone nursing practice is not feasible is

a.assessing a client’s needs based on the nurse’s perception.
b.developing a collaborative plan of care with a client.
c.evaluating outcomes of practice and care.
d.prioritizing the urgency of a client’s needs.

Answer: A
To assess a client’s needs based on a nurse’s perceptions, the nurse would need to be able to assess the nonverbal responses, which usually are not available on a phone. All other options are feasible by phone.

11. The nurse contacts a client by follow-up telephone call after the client’s visit to an ambulatory care center. The client who would benefit most from this intervention

a.has undergone cast removal.
b.has undergone same-day surgery. having blood pressure monitored. having blood sugar monitored.

Answer: B
Telephone follow-up calls are used for clients who have had ambulatory surgery or for those subject to daily changes in condition.

12. The nurse who is seeking legal guidance in delegating assignments to assist workers in an ambulatory care setting would best consult protocols.
b.recently published texts.
c.the agency’s legal counsel.
d.the state nurse practice act.

Answer: D
Nurse practice acts (NPAs) for each state define legal delegation guidelines. Agency protocols cannot override the NPA; the legal counsel would certainly reference the NPA; and texts cannot address each state’s NPA.

13. The purpose of the mutual recognition model (MRM), implemented through an interstate contract, is to

a.ensure an increasing supply of nurses entering the work force.
b.monitor the number of nurses working in more than one field of specialty.
c.provide educational incentives for nurses to continue working full-time.
d.reduce barriers to interstate nursing practice.

Answer: D
The MRM allows nurses to communicate and recommend health practices to persons out of state, thus reducing the barriers to interstate nursing practice, especially as it applies to telehealth services.

14. One challenge for nurses working in ambulatory care centers is

a.clients give overall responsibility for self-care to the center.
b.duties are rigidly defined within the interdisciplinary team.
c.length of client visit is short, reducing assessment time.
d.use of telephones and computers eases assessment potential.

Answer: C
The short time of the ambulatory care visit makes assessment difficult and makes omissions in the assessment almost impossible to correct.

15. When considering culture as the nurse is designing health plans for clients, the ambulatory care center nurse will consider least the cultural concept of

a.making food modifications culturally appropriate.
b.recognizing that cultural family roles may be rigidly defined.
c.reflecting on research data describing culturally motivated responses.
d.understanding that some cultures reject female authority.

Answer: C
Although all options are significant, options a, b, and d are considerations for client welfare and, consequently, are more important.

16. In a telephone consultation, the ambulatory care center nurse may

a.assess cardiac or fetal monitoring.
b.decide how soon the client should be seen at the center.
c.give advice based on the nurse’s phone assessment.
d.teach a specific procedure based on approved protocols.

Answer: D
The telephone consult is designed for teaching or advising the client based on prescribed protocols, not on phone assessment (option c). Triage (option b) and surveillance (option d) are not considered within the definition of “consult.”

17. After each telehealth communication the nurse should

a.immediately document the content of the call in the client’s record.
b.inform the physician of the information or teaching given.
c.schedule a later call to check on the client’s progress.
d.send the client a written form of the pertinent information.

Answer: A
All information pertinent to the call should be recorded in the client record.

18. An ambulatory care center nurse who is counseling a young client with sickle cell anemia can best access evidence-based practice (EBP) guidelines from current nursing texts or journals.
b.integrated hospital care plans and protocols.
c.the Occupational Safety and Health Administration (OSHA).
d.the Agency for Healthcare Research and Quality (AHRQ).

Answer: D
AHRQ has evidence-based guidelines for many common problems, including sickle cell anemia, and would be the best source of up-to-date evidence-based practice guidelines. “Current” textbooks are written approximately 2 years before publication. Journals have up-to-date information but might not have the subject matter needed. Hospital care plans and protocols should be based on current EBP practice, but are often outdated and based on what has always been done. OSHA’s role has nothing to do with EBP.

19. The ambulatory care center nurse assures a dubious client that she has been certified as an ambulatory nurse by

a.application to the Accreditation Association for Ambulatory Health Care.
b.membership in the National Committee for Quality Assurance.
c.passing a specialized examination.
d.working as an ambulatory care nurse for 5 years.

Answer: C
Ambulatory care nurses may be certified by passing a practice-specific examination. To qualify for the examination, nurses must have worked in ambulatory care for a certain minimum number of hours. The first two options involve agency-accrediting organizations.

20. The nurse explains that to work at an independent, nurse-supervised ambulatory care center, there is a minimum requirement of a(n)

a.associate degree.
b.bachelor’s degree.
d.master’s degree.

Answer: B
A bachelor’s degree is the minimum requirement for a nurse to work at an independent ambulatory care center.

Chapter 6: Acute Health Care

1.The prepayment plan developed in 1929 is

a.Blue Cross Health Insurance.
b.Medicare Insurance.
c.Medicaid Insurance.
d.Health Maintenance Organization.

Answer: A
The 1929 Blue Cross Plan offered a form of prepayment insurance. Medicare and Medicaid are government entitlement programs. Health maintenance organizations arose as cost-containment measures, and physicians are reimbursed at a fixed rate for each person enrolled.

2.A hospital staff nurse is collaborating with a nurse case manager in planning the care of a client with a below-the-knee amputation. The primary role of the case manager is

a.client education on specialized care.
b.coordination of care for the client. care of the client’s medical problems. of the staff nurse.

Answer: B
Case managers are nurses who coordinate the care of a group of clients, monitor the implementation of interdisciplinary care plans, and maintain communication with third-party payers and referral sources.

3.A registered nurse (RN) seeking work in a voluntary health agency would choose a hospital.
b.proprietary hospital.
c.state university hospital.
d.veterans administration (VA) hospital.

Answer: A
Voluntary agencies are not-for-profit, tax-exempt organizations designed to meet health care needs of the public.

4.A client experiences chest pain with electrocardiographic changes during an appointment with the primary care physician, and the physician orders hospital admission for cardiac monitoring. This type of admission is a(n)

a.elective admission.
b.emergency admission. admission.
d.scheduled admission.

Answer: C
A direct admission is the process followed when a client is determined to need hospital or nursing care while in a physician’s office.

5.A client for whom the nurse would provide post–acute care is the

a.38-year-old following cesarean birth.
b.40-year-old recovering from kidney stone removal.
c.60-year-old receiving a regulated regimen of anti-hypertensive medication.
d.76-year-old needing rehabilitation after cardiac surgery.

Answer: D
Post–acute care areas are designed for clients who are out of the fragile phase of their illness and need routine monitoring and rehabilitation. After childbirth and kidney stone removal, the client would most likely need inpatient care at a hospital. A client receiving anti-hypertensive medications would most likely be followed in an ambulatory care setting.

6.While administering an antibiotic to a client with an infection, the nurse explains the importance of completing the full course of antibiotic therapy. This is an example of

a.formal education. advice.
c.informal education.
d.setting an example.

Answer: C
Informal education continues throughout the course of nursing care in the form of directions and explanations. Formal education is a formal presentation.

7.When unit staffing includes unlicensed assistive personnel, the nurse is aware that

a.delegating tasks to unlicensed assistive personnel is not in the scope of RN practice.
b.licensed personnel are accountable for the tasks delegated to the unlicensed personnel.
c.unlicensed assistive personnel do not have clinical duties on a client care unit.
d.unlicensed assistive personnel have formal training and function independently.

Answer: B
Nurses remain accountable for client outcomes whether or not the specific tasks are performed by nurses or by nurse extenders.

8.When a nurse is able to work effectively in more than one care area (e.g., general medical-surgical, and cardiac care unit), the nurse is said to be

b.flexibly assigned.
c.nursing intense.
d.skill mixed.

Answer: A
In an attempt the make the most effective use of available personnel, nurses may be cross-trained to work skillfully in two or more specialty care areas. A skill mix is the ratio of RNs to LPNs and assistive personnel to deliver the highest quality care while controlling cost.

9.An applicant was denied employment with a health care agency because she is a recovering alcoholic. This action by the agency violates the

a.Age Discrimination and Employment Act.
b.Americans with Disabilities Act.
c.Civil Rights Act.
d.Occupational Safety and Health Act.

Answer: B
In 1990 the Americans with Disabilities Act was passed to eliminate discrimination against persons with physical or mental disabilities. The Age Discrimination and Employment Act protects individuals over the age of 65. The Civil Rights Act protects individuals from employment discrimination on the basis of qualifications unrelated to job performance (such as race) and promotes employment based on ability and merit. The Occupational Safety and Health Act requires places of employment to be free of hazards and requires they write and enact safety policies.

10.A planned program of loss prevention and liability control best defines

a.client satisfaction.
b.clinical pathway.
c.quality assurance.
d.risk management.

Answer: D
Risk management is a planned program of loss prevention to identify and analyze risks in an effort to reduce accidents and injuries. Client satisfaction data are usually collected after a client is discharged from a hospital or other care setting. Quality assurance is a multi-leveled plan with components such as strategic planning, budgeting, performance improvement, and other elements. A clinical pathway is a plan that directs client care and recovery from predictable problems.

Chapter 7: Critical Care

1.The population that is increasingly using critical care units and needing specialized nursing care is the population of

b.middle-age adults.
c.underserved pregnant women.

Answer: A
Clients needing critical care do span the life span; however, those ages 65 and older comprise an increasing number of such clients. Of all hospital beds, more than 50% are filled with the elderly. The physiologic changes that accompany aging, plus chronic conditions seen in this age group, lead to an increased need for critical care beds.

2.The ICU nurse planning care for a critically ill client tries to arrange care to minimize the most disruptive stressor for the client, which is

a.alteration in sleep.
b.fear of the unknown.
c.persistent pain.
d.sense of isolation.

Answer: A
There are many stressors to the ICU client, but alteration in sleep patterns supercedes all the other options.

3.Critical care units (CCUs) have been developed in almost all hospitals because such units

a.allow for concentration of expert personnel.
b.can offer special services to the family.
c.contain costs.
d.separate the seriously ill from the other clients.

Answer: A
The CCU offers a space in which a concentration of expert personnel can be assigned to monitor and apply highly technological machines such as ventilators. The concentration of personnel does not reduce cost.

4.The nurse admitting clients to the critical care unit understands that priority clients for this area are those who need

a.a cleaner environment to prevent nosocomial infections.
b.continuous physiologic monitoring.
c.frequent vital sign checks.
d.private rooms conducive to rest and sleep.

Answer: B

5. The nurse admitting clients to an intensive care unit understands that research demonstrates best client outcomes when clients

a.are in an area that allows liberal family visitation.
b.have consistent nurses caring for them.
c.have state of the art physiologic monitoring.
d.receive multidisciplinary care led by an intensivist.

Answer: D
Studies showed a 30% reduction in intensive care unit stay when care was delivered by an intensivist-lead multidisciplinary team as opposed to an attending physician.

6.A nurse who is acting in a manner that respects and supports the client’s and family’s basic rights, values, and beliefs is functioning in which professional role?

c.Critical thinker

Answer: A
See Box 7-3 for more description of advocacy in critical care. A nurse functioning in the caregiver role provides bedside care. A critical thinker evaluates all options and chooses the best response when faced with a dilemma. A manager coordinates care.

7.A nurse working in critical care would plan interactions with clients’ families based on the understanding that families most need

d.spiritual support.

Answer: A
Studies consistently show that the family’s need for knowledge is consistent. While all options are valid, need-to-know is most important. Nurses tend to greatly underestimate their role in keeping families’ needs satisfied. Providing information from one consistent nurse is very valuable and helpful to most families.

8.A nurse working in the critical care unit would assess the client’s complexity by asking questions related to

a.ability of the client and family to make sound decisions.
b.effect of family, stress, and environmental factors on the client.
c.interplay of multiple medical problems on the current condition.
d.the client’s ability to use compensatory coping mechanisms.

Answer: B
Complexity is a client characteristic that assesses the intricate entanglement of two or more systems, such as physiologic, emotional, family, and environment. Option a refers to participation in decision-making, option c is not a client characteristic, and option d is resiliency.

9.The essential nurse competency that the critical care nurse uses when providing best care practices is

b.clinical inquiry.
c.clinical judgment. thinking.

Answer: B
Advocacy is working on another’s behalf when that person is not capable of advocating for himself/herself. Clinical judgment is the reasoning used by a health care provider when delivering care. Systems thinking is using tools and knowledge to work within the interconnected health care system. Clinical inquiry is the ongoing process of questioning and evaluating practice, providing informed practice, and innovating through research and experiential learning. All are essential nurse competencies for the critical care nurse.

10. A critical care nurse understands that stressors affecting both the client and the client’s family include (Select all that apply)


Answer: A, B, C, D
Clients and their families have multiple stressors in the critical care environment. Lack of privacy is one of them as are the other four options.

Medical Surgical


Disseminated intravascular coagulation, formerly termed as disseminated intravascular coagulopathy, is not a disease but a sign of an underlying condition. DIC may be triggered by sepsis, trauma, cancer, shock, abruptio placenta, toxins or allergic reactions. The severity of DIC is variable, but it is potentially life-threatening.


 Normal homeostatic mechanism are altered in DIC so that a massive amount of tiny clots forms in the microcirculation. Initially, the coagulation time is normal. However, as the platelets and clotting factors are consumed to form the microthrombi, coagulation fails. Thus, the paradoxical result of excessive clotting is bleeding. The clinical manifestations of DIC are reflected i the organs, which are affected either by excessive clot formation (with resultant ischemia to all or part of the organ) or by bleeding. The excessive clotting triggers the fibrinolytic system to release fibrin degradation products, which are potent anticoagulants, furthering the bleeding. The bleeding is characterized by low platelet  and fibrinogen level; prolonged PT, PTT, and thrombin time; and elevated fibrin degradation products (D-dimers).

Identification of patients who are at risk  for DIC and recognition of the early clinical manifestations of this syndrome can result in earlier medical intervention, which may improve the prognosis. However, the primary prognosis factor is the ability to treat the underlying condition that precipitated DIC.


Patients with frank DIC may bleed from mucous membranes, venipuncture sites, and the GI and urinary tracts. The bleeding can range from minimal occult internal bleeding to profuse hemorrhage from all orifices.  The patient may also develop organ dysfunction, such as renal failure and pulmonary and multifocal central nervous system infarctions, as a result of microthromboses, macrothromboses, or hemorrhages. During the initial process of DIC, the patient may have no new symptoms, the only manifestations being  a progressive decrease in the platelet count. As the thrombosis becomes more extensive, the patients exhibits signs and symptoms of thrombosis in the organs involved. Then, as the clotting factors and platelets are consumed to form these thrombi, bleeding occurs. Initially the bleeding is subtle, but it can develop into frank hemorrhage.


The most important management factor in DIC is treating the underlying cause ; until the cause is controlled, the DIC will persist. Correcting the secondary effects of tissue ischemia by improving oxygenation, replacing fluids, correcting electrolyte imbalances, and administering vasopressor medications is also important.  If serious hemorrhage occurs, the depleted coagulation factors and platelets may be replaced to reestablish  the potential for normal hemostasis and thereby diminish bleeding. Cryoprecipitate is given to replace fibrinogen and factors V and VII; fresh frozen plasma is administered to replace other coagulation factors. A controversial treatment strategy is to interrupt the thrombosis process through the use of heparin infusion. Heparin may inhibit the formation of microthrombi and thus permit perfusion of the organs (skin, kidneys or brain) to resume. Heparin use was traditionally reserved   for patients in whom thrombotic manifestations predominated or in whom extensive blood component replacement failed to halt the hemorrhage or increased fibrinogen and other clotting levels. Heparin is now considered also applicable for use in less acute forms of DIC (Leung, 2004). The effectiveness of heparin can best be determined by observing for normalization of the plasma fibrinogen concentration and diminishing  signs of bleeding. Fibrinolytic inhibitors, such as aminocaproic acid (EACA), Amicar), may be used with heparin. Other therapies include recombinant activated protein C (APC; drotrecogin alfa [Xigris]), which is effective in diminishing inflammatory responses on the surface of the vessels as well as having anticoagulant properties (Aird, 2004).  Bleeding is common, can occur at any site, and can be significant. Antithrombin (AT) infusions can also be used for their anticoagulant and anti-inflammatory properties. Bleeding can be significant, particularly when administered in association with heparin.


Reference: Suzanne C. Smeltzer, Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th edition Lippincott Williams & Wilkins pp. 1093-1094

Medical Surgical


Buerger’s disease is characterized by recurring inflammation of the intermediate and small arteries and veins of the lower and (in rare case) upper extremities. It results in thrombus formation and occlusion of the vessels. It is differentiated from other vessel diseases by it microscopic appearance. In contrast to atherosclerosis, Buerger’s disease is believed to be an autoimmune disease that results in occlusion of the distal vessel.

The cause of Buerger’s disease is unknown, but it is believed to be an autoimmune vasculitis. It occurs most often in men between 20 and 35 years of age, and it has been reported in all races and in many areas of the world. There is considerable evidence that heavy smoking or chewing of tobacco is a causative or aggravating factor (Mills, 2003). Generally, the lower extremities or viscera can also be involved. Buerger’s disease is generally bilateral ans symmetric with focal lesions. Superficial thrombophlebitis may be present.


                  Pain is the outstanding symptom of Buerger’s disease. the patient complain of foot cramps, especially the of the arch (in-step claudication), after exercise. The pain is relieved by rest; often, a burning pain is aggravated by emotional disturbances, nicotine, or chilling. Cold sensitivity of Raynaud type is found in half of the patients and is frequently confines to the hands. Digital rest pain is constant, and the characteristics of the pain do not change between activity and rest.

                 Physical signs include intense rubor (reddish-blue discoloration) of the foot and absence pedal pulse, but normal femoral and popliteal pulses. Radial ans ulnar artery pulses are absent or diminished.  Various type of paresthesia develop.

As the disease progresses, definite redness or cyanosis of the part appears when extremity is in dependent position. Involvement is generally bilateral, but color changes may affect only one extremity or only certain digits. Color changes may progress to ulceration, and ulceration with gangrene eventually occurs.


              Segmental limb blood pressures are taken to demonstrate the distal location of the lesions or occlusions. duplex ultrasonography is used to document patency of the proximal vessels and to visualize the extent of distal disease. Contrast angiography is used to identify the diseased portion of the anatomy.

Gerontologic Considerations

              In older patients, Buerger’s disease may be followed by atherosclerosis of the larger vessels after involvement of the smaller vessels. The patients ability to walk may be severely limited. Patients are at higher risk for non healing wounds because of impaired circulation.


              The treatment of Buerger’s disease is essentially the same as that for atherosclerotic peripheral arterial disease. The main objectives are to improve circulation to the extremities, prevent the progression of the disease, and protect the extremities from trauma and infection. Treatment of ulceration and gangrene is directed toward minimizing infection and conservative debridement of necrotic tissue. Tobacco use is highly detrimental, and patients are strongly advised to completely stop using tobacco. symptoms are often relieved by cessation of tobacco use.

             Vasodilators are rarely prescribed because these medications cause dilation of only healthy vessels; vasodilators may divert blood away from the partially occluded vessels, thus exacerbating the manifestations of the disease. A regional sympathetic blocker or ganglionectomy may be useful in some instances to produce vasodilation and increase blood flow.

            If gangrene of a toe develops as a result of arterial occlusive disease in the leg, it is unlikely that toe amputation or even transmetatarsal amputation will be sufficient; often, a below-knee amputation pr occasionally above-knee amputation is necessary. The indications for amputation include gangrene, especially if the infected area is moist; severe rest pain; or fulminating sepsis.


            The patient is assisted in developing and implementing a plan to stop using tobacco and to manage pain. The patient may need to be encouraged to make the lifestyle changes necessary to adequately manage a chronic disease, including modifications in diet, activity, and hygiene (skin care). The nurse determines whether the patient has a network of family and friends to assist with ADLs. The nurse ensures that the patient has the knowledge and ability to assess for any postoperative  complications such as infection and decreased blood flow.

Reference: Suzanne C. Smeltzer,, Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th edition

Lippincott Williams & Wilkins pp. 995-996

Medical Surgical

Pulmonary Emphysema

Pulmonary emphysema is defined as a nonuniform pattern of abnormal, permanent distention of the air spaces  with destruction of the alveolar walls and eventually a reduced pulmonary capillary bed. It appears to be the end stage of a process that has progressed slowly for many years. Smoking is the major cause. In a few patients, there is familial predisposition associated with a plasma protein abnormality ( deficiency in alpha-1 antitrypsin), making the person sensitive  to environmental factors ( air pollution, infectious agents, allergens). Emphysema  manifests commonly in the fifth decade of life and is classified as follows:

  • Panlobular (panacinar): characterized by destruction of respiratory bronchiole, alveolar duct, and alveoli; air spaces within the lobule are enlarged  with little inflammatory disease.
  • Centrilobular (centriacinar): cause pathologic changes in the center of the secondary lobule, producing chronic hypoxemia, hypercapnia, polycythemia, and episodes of right-sided heart failure.

Both types of emphysema can occur together.  

Clinical Manifestations

  • Dyspnea with insidious onset progressing to severe dyspnea with slight exertion (major symptom)
  • Chronic cough, hyperinflated “barrel chest” due to air trapping, muscle wasting, and pursed-lip breathing
  • On ausculatation, diminished breath sounds with crackles, wheezes, rhonchi, and prolonged expiration.
  • Hyperresonance with percussion and a decrease in fremitus .
  • Anorexia, weight loss, weakness, and inactivity.
  • Hypoxemia and hypercapnia, morning headaches in advanced stages.
  • Inflammatory reactions and infections from pooled secretions.

Assessment and Diagnostic Method Evaluation entails primarily chest x-rays,  chest computed tomography CT) scans, pulmonary function tests, pulse oximetry, blood gases, and complete blood count.

Complications Right-sided heart failure  (cor pulmonale) leading to central cyanosis and respiratory failure

Medical ManagementThe major goals of medical management are to improve quality of life, slow progression of the disease, and treat obstructed airways to relieve hypoxia. Treatment is directed at improving ventilation, decreasing work of breathing and preventing infection.

  • Smoke cessation
  • Physical therapy to conserve and increase pulmonary ventilation
  • Maintenance of proper environmental conditions to facilitate breathing
  • Psychological support
  • Ongoing program of patient education ans rehabilitation
  • Bronchodilators and metered-dose inhalers (aerosol therapy, dispensing particles in fine mist)
  • Treatment of infection (antimicrobial therapy at the first sign of respiratory infection).
  • Oxygenation in low concentrations for severe hypoxemia

Reference: Joyce Young Johnson, Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 11th edition Lippincott Williams & Wilkins pp. 331-333

Medical Surgical

Anemia, Megaloblastic (Vitamin B12 and Folic Acid Deficiency)

The anemias caused by deficiencies of the vitamins B12 and folic acid show identical bone marrow and peripheral blood changes. Both vitamins are essential for DNA synthesis.


The two main vitamin deficiencies may coexist. In each case, hyperplasia of the bone marrow occurs, and the precursor erythroid and myeloid cells are large and bizarre in appearance. The RBC’s produced are abnormally large (megaloblastic). A pancytopenia (a decrease in all myeloid-derived cells) develops.

Vitamin B12 deficiency can occur from inadequate intake in strict vegetarians; faulty absorption from gastrointestinal tract; absence of intrinsic factor (pernicious anemia); disease involving the ileum or pancreas, which impairs B12 absorption; and gastrectomy. People with pernicious anemia have a higher incidence of gastric ulcer than the general public.

Folic acid deficiency occurs when intake of folate is deficicnet or the requirement is increased. People at risk include those who rarely eat uncooked vegetables or frutis, primarily elderly people living alone or people with alcoholism. Alcohol use, hemolytic anemia, and pregnancy increase folic acid requirements. Patients  with malabsoptive or small bowel disease may not absorb folic acid normally.

Clinical Manifestations

Symptoms are progressive and may be marked by spontaneous partial remissions and exacerbations.

  • Gradual development of signs of anemia (weakness, listlessness, and pallor)
  • Possible development of a smooth, sore, red, tongue and mild diarrhea (pernicious anemia)
  • Possible development of confusion, more often, paresthesias in the extremities ad difficulty keeping balance, loss of position sense
  • Lack of neurologic manifestations with folic acid deficiency alone
  • Vitiligo (patchy loss of skin pigmentation) and prematurely graying hair (often seen in pernicious anemia)
  • Without treatment, patients die, usually as a result of congestive heart failure from anemia

Assessment and Diagnostic Findings

  • Schilling test (primary diagnostic tool)
  • Complete blood count (Hgb value as low as 4 to 5 g/dl, WBC count 2,000 to 3,000/mm3, platelet count less than 50,000/mm3, MCV is very high, usually exceeding 110)
  • Serum levels of folate and vitamin B12 (folic acid deficiency and deficient vitamin B12)

Medical Management: Vitamin B12 Deficiency

  • Oral supplementation with vitamins or fortified soy milk (strict vegetarians)
  • Intramuscular injections of vitamin B12 for defective absorption or absence of intrinsic factor
  • Prevention of recurrence with lifetime vitamin B12 therapy for patient who has had pernicious anemia or non correctable malabsorption

Medical Management: Folic Acid Deficiency

  • Intake of nutritious die and 1 mg folic acid daily
  • Intramuscular folic acid for malabsorption syndromes
  • Folic acid taken orally as a separate tablet (except prenatal vitamins)
  • Folic acid replacement stopped when hemoglobin level returns to normal, with the exception of alcoholics, who continue replacement as along as alcohol intake continues

Nursing Management

  • Assess patients at risk for megaloblastic anemia for clinical manifestations (eg, inspect the skin, sclera, and mucous membranes for jaundice, note vitiligo or premature graying or smooth, red, sore tongue).
  • Perform careful neurologic assessment (eg, note gait and stability; test position and vibration sense).
  • Assess need for assistive devices (eg, cane, walkers) ans need for support and guidance in managing activities of daily living and home environment.
  • Ensure safety when position sense, coordination, and gait are affected.
  • Refer for physical or occupational therapy as needed.
  • When sensation is altered, instruct patient to avoid excessive heat and cold.
  • Advise patient to prepare bland, soft foods and to eat small amounts frequently.
  • Explain that other nutritional deficiencies, such as alcohol-induced anemia, can induce neurologic problems.
  • Instruct patient in complete urine collections for the Schilling test. Also explain the importance of the test and of complying with the collection.
  • Teach the patient about chronicity of disorder and  need for monthly vitamin B12 injections when patient has no symptoms. Instruct patient how to self-administer injections, when appropriate.
  • Stress importance of ongoing medical follow-up and screening, because gastric atrophy associated with pernicious anemia increases the risk of gastric carcinoma.

Reference: Joyce Young Johnson, Brunner & Sudddarth’s Textbook of Medical-Surgical Nursing 11th edition Lippincott Williams & Wilkins pp. 45-48